Page 20 - JSOM Winter 2022

Incidence of Airway Interventions
in the Setting of Serious Facial Trauma

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Steven G. Schauer, DO, MS *; Jason F. Naylor, PA-C ; Andrew D. Fisher, MD, MPAS ;
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Tyson E. Becker, MD ; Michael D. April, MD, DPhil, MSc 5
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ABSTRACT
Background: Airway obstruction is the second leading cause placement. It is also often faster to place and sufficient for the
of preventable death on the battlefield. Most airway obstruc- shorter transport times in the civilian setting. However, the
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tion occurs secondary to traumatic disruptions of the airway signature mechanism of injury of the recent conflicts in Iraq
anatomical structures. Facial trauma is frequently cited as and Afghanistan – explosive trauma – creates injury patterns
rationale for maintaining cricothyrotomy in the medics’ skill not seen in the civilian setting.
set over the supraglottic airways more commonly used in the
civilian setting. Methods: We used a series of emergency de- Casualties with facial trauma requiring airway intervention
partment procedure codes to identify patients within the De- have high mortality. Previous reports on US military prehos-
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partment of Defense Trauma Registry (DoDTR) from January pital airway intervention among battlefield casualties, includ-
2007 to August 2016. This is a sub-group analysis of casualties ing those without serious facial trauma, describe a combined
with documented serious facial trauma based on an abbrevi- total of 348 cricothyrotomies with a procedure incidence rate
ated injury scale of 3 or greater for the facial body region. of 0.25–2.4%. Mortality rates were reported from 45% to
Results: Our predefined search codes captured 28,222 DoDTR 90%. 8–15 As such, the cricothyrotomy remains in the medics’
casualties, of which we identified 136 (0.5%) casualties with skill set of airway management options for this specific popula-
serious facial trauma, of which 19 of the 136 had documenta- tion. A previous report from the combat setting demonstrated
tion of an airway intervention (13.9%). No casualties with se- a 33% failure rate with medic performed cricothyrotomy.
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rious facial trauma underwent nasopharyngeal airway (NPA) Additionally, complications reported mirrored that of the ci-
placement, 0.04% underwent cricothyrotomy (n = 10), 0.03% vilian literature – misplacement, excessive bleeding, failure to
underwent intubation (n = 9), and a single subject underwent cannulate, etc.
supraglottic airway (SGA) placement (<0.01%). We only iden-
tified four casualties (0.01% of total dataset) with an isolated Cricothyrotomy is a technically challenging and rarely per-
injury to the face. Conclusions: Serious injury to the face rarely formed procedure even for physicians. Maintaining currency
occurred among trauma casualties within the DoDTR. In this with this procedure is a particular challenge for medics who
subgroup analysis of casualties with serious facial trauma, the have infrequent training and opportunities for skill main-
incidence of airway interventions to include cricothyrotomy tenance. It remains unclear whether the military should
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was exceedingly low. However, within this small subset the continue to promote this method of airway management, es-
mortality rate is high and thus better methods for airway man- pecially outside of the Special Operations community in which
agement need to be developed. their medics have more advanced training, more frequent sus-
tainment, and more combat trauma experience with airway
Keywords: prehospital; airway; facial; trauma; military management. 8

Goal of This Investigation
Background
We seek to build on previously published data and determine
Airway obstruction is the second leading cause of potentially the incidence of prehospital cricothyrotomy among casualties
preventable death on the battlefield. Tactical Combat Ca- with serious facial trauma. 10,18
1,2
sualty Care (TCCC) guidelines recommend the use of posi-
tional maneuvers followed by NPA placement followed by the Methods
placement of SGA or cricothyrotomy if SGA placement is not
feasible (e.g., casualty is not obtunded, etc.). Endotracheal in- Ethics
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tubation (ETI) is usually performed only by medical officers The US Army Institute of Surgical Research regulatory office
or Special Operations medics later once the casualty reaches a reviewed protocol H-16-005 and determined it was exempt
more controlled setting. Civilian medics commonly utilize SGA from Institutional Review Board oversight. We obtained only
devices in lieu of ET as it requires less experience for successful deidentified data.
*Correspondence to steven.g.schauer.mil@health.mil
1 Steven G. Schauer is a physician affiliated with the US Army Institute of Surgical Research and the Brook Army Medical Center, JBSA Fort Sam
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Houston, TX, in addition to the Uniformed Services University of the Health Sciences, Bethesda, MD. Jason F. Naylor is a physician assistant
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affiliated with Madigan Army Medical Center, Joint Base Lewis McChord, WA. Andrew D. Fisher is a physician assistant affiliated with Medical
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Command, Texas Army National Guard, Austin, TX, and University of New Mexico Hospital, Albuquerque, NM. Tyson E. Becker is a physician
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affiliated with Brooke Army Medical Center, JBSA Fort Sam Houston, TX. Michael D. April is a physician affiliated with the 40th Forward
Resuscitative Surgical Detachment, Fort Carson, CO, in addition to the Uniformed Services University of the Health Sciences, Bethesda, MD.
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